Student Support Services/TRiO
Program Application
NOTE: Before filling in the application -- be prepared. You will need income information
and disability documentation (if it applies to you). Have this information ready before
you start.
Open up the form and review:
IV. Income Documentation section
V. Disability Documentation section (if this applies to you).
1. Open up the form
2. Fill-in the form (you can fill-in this form online) type in all the fields that are
3. Once the form is completed, SAVE the file.
From your browser window [ File—>Save As a PDF ] Save to your downloads
folder on your computer.
4. Once the form is filled-in and saved:
email your application form and any other necessary documentation as
attachment files to: Frances Alvarado at
How will I get Notified?
We will contact you via phone call as well as an email to schedule an in-take
interview with you.
2019-2020 Cohort
Indian River State College provides equal employment and educational
opportunities to all without regard to race, color, national origin, ethnicity, sex,
pregnancy, religion, age, disability, sexual orientation, marital status, veteran
status, genetic information, and any other factor protected under applicable
federal, state, and local civil rights laws, rules and regulations. The following
person has been designated to handle inquiries regarding non-discrimination
Adriene B. Jefferson, Equity Officer & Title IX Coordinator
IRSC Main Campus ▪ 3209 Virginia Ave. ▪ Fort Pierce, FL 34981
(772) 462-7156
Student Support Services/TRiO
Program Application
2019-2020 Cohort
Student Support Services is a federally-funded program that provides academic support to a
limited number of those who qualify. Acceptance of this application does not guarantee acceptance into the program.
I. Demographic Data (PLEASE PRINT): Student ID:
Full Name:
(Last) (First) (Middle)
(City) (State) (Zip Code)
Cell Phone Number: Home Phone Number: ___________________________
Student Email Address: Email Address: __________________________________
Sex: Female Male
Are you a U.S. Citizen? Yes No If “No,” Resident Alien? A#:
Date of Birth: Place of Birth:
Marital Status (optional): Single Married Divorced Widowed
Ethnicity American Indian or Alaska Native Asian Black or African-American
(Select all that apply.) Native Hawaiian or Other Pacific Islander Hispanic/Latino White
Did you participate in other TRIO/Outreach Programs? (Select all that apply)
Educational Talent Search Upward Bound Upward Bound-Indian River County
Upward Bound Math Science Farmworker Career Development Program LEAP
CROP Take Stock in Children Summer Bridge
Women of Color (WOC) Men of Color (MOC)
II. Academic Information:
Are you accepted for enrollment at Indian River State College? Yes No Campus:
Start in: Fall 19 Spring 20 Summer 20
Educational Status: Freshman (0-30 credits) Sophomore (31-60 credits) GPA:
Enrollment Status: Full-time More than Part-time (3/4 time) Part-time (1/2 time) Less than Part-time (less than 1/2 time)
Major: Expected Graduation Date:
Are you a Transfer Student? Yes No If yes, from where?
III. Eligibility:
First Generation documentation: Highest level of school completed by: (You are considered first generation if neither of your parents has a 4-year college
Mother: Middle/Junior High High School GED® Some College Bachelor’s Degree
Father: Middle/Junior High High School GED® Some College Bachelor’s Degree
GED® is a registered trademark of the American Council on Education (ACE) and administered exclusively by GED Testing Service LLC
under license. This material is not endorsed or approved by ACE or GED Testing Service.
Student’s Typed Name
2019-2020 Cohort
IV. Income Documentation:
Are you: a dependent or independent? (24 years of age or other financial aid & federal guidelines)
Number in family:
You must provide current financial documentation or complete a FAFSA® for program requirements.
Student’s Typed Name
To determine your taxable income, refer to your and/or parents’ 2018
Federal income tax return:
Line 6 on Form 1040 EZ
Line 27 on Form 1040 A
Line 43 on Form 1040
If you are applying to the SSS program as a low income participant, you
will need to submit a verification of income to the SSS office. The term
“low-income” means an individual whose family’s taxable income for
the preceding year did not exceed 150 percent of the poverty level
Size of Family
Taxable Income Less Than
For family units with more than 8 members,
add $6,630
for each additional family
V. Disability Documentation:
Are you a student with a disability? Yes No
Have you registered with the IRSC Student Accessibility Services (SAS)? Yes No
Note: Documentation of your disability is required. Disability documentation for any Indian River State College student is retained in
confidential files in the Student Accessibility Services Office.
VI. Participants Requirements:
a. I give permission for Student Support Services personnel to access my IRSC academic and student financial aid records for the purpose of verifying
my project eligibility and assisting me academically.
b. I agree to actively participate in Student Support Services activities, including: annual orientation, setting long & short-term goals, development
and updates of a personal education plan and Guided Pathway, Achievers Club, individual tutoring, Success Skills workshops, individual counseling,
cultural enrichment and college tours.
c. Submit verification of income documentation.
d. If disabled, documentation of disabled student status from the Student Accessibility Services Office.
The information I have provided is true and correct to the best of my knowledge. I attest that the documents I have presented for verification of eligibility
are genuine and relate to me. I am aware that any false documents in connection with eligibility will be cause for my dismissal from the STUDENT
SUPPORT SERVICES/TRIO PROGRAM. I also authorize Indian River State College or other postsecondary institutions to release official transcripts, test
scores, financial aid award information and other records to the Indian River State College Student Support Services/TRIO Program for educational
planning purposes. I also authorize Indian River State College Student Support Services/TRIO program to release these records to other institutions as
they relate to my educational planning.
Student’s Typed Name Date
By typing my name below indicates that my child is under 18 years of age and that the information given on this application is true and complete to the
best of my knowledge.
Parent’s Typed Name Date
VII. Release & Waiver of Liability:
As a student of Indian River State College, I hereby acknowledge that membership in the Student Support Services program (SSS) will involve participation in
extracurricular and recreational activities, as well as off-campus student trips. Furthermore, as the undersigned, I hereby release and forever discharge the SSS
program, the Board of Trustees and President of Indian River State College, its members individually, its officers, agents and employees, from any and all claims,
demands, rights, and causes of action and all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property and consequences
thereof, resulting from participation in or in anyway connected with such activities of the Student Support Services program.
I have read the above carefully before typing my name and fully understand its content. Furthermore, I understand that this release and waiver of liability shall
remain in effect for the duration of my membership and participation in the Student Support Services program.
Student’s Typed Name Date
CONFIDENTIALITY OF INFORMATION The personal information that is provided to the Student Support Services/TRIO Program will be protected under the Family
Educational Rights and Privacy Act of 1974. No one will have access to the information unless he or she works with or for the Student Support Services/TRIO
Program or is specifically authorized by the student in question to see the information. The information is necessary to help determine the success of participants
in post-secondary education as authorized by the U.S. Department of Education. (20 United States code 1231a)